TRAVELERHISTORY FORM
Complete this form and bring it to the clinic appointment along with all immunization records.
Name:DOB:Male Female
Home Phone: Work Phone: Mobile Phone:
Home Address:
City:State:Zip:
Email:
Primarycarephysician:Phone:
PatientID#: Primaryinsurance:
Doesyour insurance cover:
Health care overseas? Yes No Notsure
Medical evacuation? Yes No Notsure
Birth country:
TRAVEL PLANS (list additional information on back of form if needed):
Purpose of trip (check all that apply)
Vacation Education/research Adoption  Visit friends or family  Missionary/volunteer/humanitarian relief
 Work (urban, office-based, or conference)  Work (rural, outdoors, or in local community)  To obtain medical or dental care  Other
Planned activities(list all):
Will you be:
Visiting areas that are:
  • Rural  Yes  No  Not sure
  • Urban  Yes  No  Not sure
  • Primitive or remote  Yes  No  Not sure
Ascending to high altitudes (8,000 ft or higher)?  Yes  No  Not sure
Working with potential exposure to body fluids (e.g., medical or dental work)?  Yes  No  Not sure
Working with exposure to animals?  Yes  No  Not sure
Potentially having new sexual partners?  Yes  No  Not sure
Accommodations (check all that apply):
 Resort/large hotel  Small hotel/guest house/B&B  Cruise ship  Private home (with locals) Private home (with relatives)
 Private home (expatriate or high-end)  Primitive camping  Up-scale camp/lodge  Dormitory/ hostel
Other
Previous international travel(year/destination):
Countries and cities in order of visit / Arrival Date / Departure Date

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Name / DOB / Date
HEALTH HISTORY (Check all that apply)
Allergies
 Antibiotics (e.g., penicillin, sulfa)
 Other medications
 Egg
 Latex
 Gelatin
 Yeast
 Bees/wasps
 Seasonal
 Other
 Side effects/reactionsfrom previous medications (e.g., nausea,dizziness, stomachupset):
Cancers/blood disorder
 Coagulation disorder
 History of cancer or blood disorder
 Other
Cardiovascular
 Arrhythmia (rhythm disturbance considered significantly abnormal including atrial fibrillation, heart block)
 Implanted pacemaker or automatic defibrillator
 Heart attack
 High cholesterol
 High blood pressure
 Stroke
 Other
Endocrine
 Diabetes
 Thyroid disease
 Other
GI
 Crohn’s disease or ulcerative colitis
 IBS
 GERD
 Chronic hepatitis
 Cirrhosis or liver failure
 Other / Immune system
 Steroids by mouth within last 3 months
 Immune suppressive medications or treatments within last 3 months (e.g., radiation, cancer chemotherapy drugs, methotrexate, azathioprine, adalimumab, anakinra, etanercept, infliximab, leflunomide, rituximab)
 Spleen removed
 Thymus disease or thymectomy
 HIV/AIDS
  • Most recent CD4:
  • Most recent viral load:
 Organ, bone marrow, stem cell transplant
 Other
Kidneys
 Dialysis
 Kidney insufficiency
 Other
Lungs
 Asthma
 Emphysema/COPD
 Other
Musculoskeletal
 RA
 Psoriatic arthritis
 Other
Neurologic/psychiatric
 Seizures or epilepsy
 Anxiety /depression
 History of Guillain-Barré
 Other
Skin
 Psoriasis
 Other
OB/GYN
 Pregnant: weeks/trimester
 Breastfeeding
 Possible pregnancy in next 3 months
 Other
VACCINATION HISTORY
(Please bring all vaccination records to your appointment.)
Have you received the following immunizations?
Hepatitis A YesWhen?  No Not sure
Hepatitis B YesWhen?  No Not sure
Meningococcal YesWhen?  No Not sure
Measles/Mumps/Rubella YesWhen?  No Not sure
Polio YesWhen?  No Not sure
Tetanus YesWhen?  No Not sure
Typhoid YesWhen?  No Not sure
Yellow Fever YesWhen?  No Not sure
Japanese Encephalitis YesWhen?  No Not sure
Influenza  YesWhen?  No Not sure
Other
Have you ever had an adverse reaction to an immunization?  No  Yes Explain:

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Name / DOB / Date
CURRENT MEDICATIONS
Prescription medications: List all current prescription medications
Medication / Reason for use/medical condition
Non-prescription products: List current over-the-counter, herbal, homeopathic products, vitamins, supplements, etc.
Product / Reason for use/medical condition
QUESTIONS/CONCERNS
Additional questions or concerns about your travel:
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